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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 315920040
Report Date: 05/29/2024
Date Signed: 05/29/2024 04:16:04 PM


Document Has Been Signed on 05/29/2024 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827



FACILITY NAME:SIERRA RIDGE SENIOR LIVINGFACILITY NUMBER:
315920040
ADMINISTRATOR:JENNIFER FUSTONFACILITY TYPE:
740
ADDRESS:3625 BLUE OAKS DRTELEPHONE:
(530) 718-1553
CITY:AUBURNSTATE: CAZIP CODE:
95602
CAPACITY:65CENSUS: 47DATE:
05/29/2024
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
03:00 PM
MET WITH:Jennifer Fuston; TIME COMPLETED:
04:30 PM
NARRATIVE
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On 5/29/2024 LPA Tryon visited the facility to follow up on an incident that was reported by the facility on 5/24/24 and dated 5/23/24. LPA met with ED Jennifer Fuston and Director of Health and Wellness Kaitlyn Sutherland.
On 5/23/24 a POA for a resident reported that there was concern that a medication had not been given to resident R1 based on the resident's condition at a medical appointment on 5/14/24. The ED and Director of Health and Wellness immediately investigated, and found that staff S1 had signed on the Electronic Medication Administration Record (EMAR) that the medication was being given as per doctor order. Further investigation revealed that the medication had NOT been given, possibly for some period of time. This put R1 at potential serious risk to health and safety. The employment of R1 was terminated, and the medication was re-started as per doctor order. Administrator made appropriate reports to CCL, POA, LTC Ombudsman and Placer County Sheriff. R1 did have a follow-up medical appointment on 5/28/24 and is doing well, the health issue has returned to normal baseline at this time.

The following deficiency is cited as per Title 22 Regulations. Appeal Rights provided, exit interview conducted.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 05/29/2024 04:16 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827


FACILITY NAME: SIERRA RIDGE SENIOR LIVING
FACILITY NUMBER: 315920040

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 05/29/2024
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type A
05/29/2024
Section Cited
CCR
87465(a)(4)

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The licensee shall assist residents with self-administered medications as needed.
This requirement was not met as evidenced by: Through review of records and interview of staff it was learned that staff S1 had signed on the MAR daily that a prescribed medicaton was being given to resident R1
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The Administrator will ensure that each resident is receiving all of their medication as prescribed.
The Administrator and DHW immediately investigated, found that the medication was not being given, and had it re-started. The staff involved was terminated, R1 received a
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daily. However, it was learned that the medication had NOT been given to R1 for some time, causing a potential health and safety risk to R1.
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follow-up medical check and is back at normal baseline for the issue. Medication staff received in-service training on 5/28/24. POC is complete.

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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Troy OrdonezTELEPHONE: (916) 263-4832
LICENSING EVALUATOR NAME: Todd TryonTELEPHONE: (916) 263-4700
LICENSING EVALUATOR SIGNATURE:
DATE: 05/29/2024
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 05/29/2024
LIC809 (FAS) - (06/04)
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